Discussion
Those outlining the advantages of medicalisation might note that it:
quickly and efficiently enables access to medical treatments
can increase the reliability of diagnoses through its use of rigid categories
provides clear, succinct categories that can be tested and modified.
Those outlining the drawbacks might note that it:
restricts the ability to explore contextual and individual factors
can reduce the validity of diagnosis, particularly as new disorders might be proposed for experiences not previously regarded as mental health problems
can result in overly broad diagnostic categories
can lead to the prescription of unnecessary medication.
5.3 The continuing impact of the DSM
The DSM continues to have a significant impact on research. Additionally, although the NIMH appears to be distancing itself from the DSM, many other research funding bodies continue to fund studies based on its diagnostic categories. This has an impact on clinical practice: in the UK, the National Institute for Health and Care Excellence publishes clinical guidelines on particular ‘conditions’ which draw on research findings using ICD and DSM categories.
Mental health services are increasingly organised by diagnostic categories. The high levels of comorbidity (a medical term used to denote when two or more conditions co-occur) that arise when categories such as those of the DSM are used can create problems; to which service should a person with a diagnosis of both depression and personality disorder be referred, for instance? There is an increasing proliferation of diagnosis-specific adaptations of therapies, such as cognitive behavioural therapy (CBT) for psychosis, CBT for anxiety, and so on. The use of diagnosis by health insurers and the NHS can cause a range of dilemmas. What if a clinician thinks that a person needs help but their problems do not map easily on to diagnostic categories? What if someone does not wish to receive a diagnosis? What if a professional feels that the use of diagnosis is pathologising? How can couple and family therapists record their work using a system that provides categories only for individuals?
The debate about DSM-5 has again prompted questions about how we understand mental health and the role of social norms. The reliability problem has returned, while diagnosis has expanded further into everyday life. Rates of diagnosis and medication for some problems have increased. This has led to questions being raised about the influence of the pharmaceutical industry. Diagnostic manuals such as the DSM continue to have an impact on both research and mental health services.
Conclusion
Psychiatric diagnosis involves the application of a medical framework to problems in living. By comparing people’s reported problems against the criteria found in diagnostic manuals such as the DSM, the closest-matching diagnostic category or categories can be identified. This chapter has explored whether a medical framework can appropriately be applied to mental health. It has also examined the process of medicalisation, by which problems in living can come to be viewed as mental illnesses. In the case of PTSD, the medicalisation of the condition was welcomed by activists for Vietnam veterans, whereas gay and lesbian activists campaigned to de-medicalise homosexuality and feminists have criticised the inclusion of PMDD in the DSM.
The content of the DSM has changed over the sixty years between its first and fifth editions. It has changed from being a brief list of categories designed to produce statistics on the characteristics of adult patients in asylums to a larger, more detailed manual with a much broader scope. The DSM now covers the entire lifespan – including problems of varying severity – across a broader range of settings and serves a wider range of functions.
This chapter has identified shifts in the theoretical models that have informed the DSM – from the broadly organic and psychodynamic approach of the first two editions, through to the more biomedical approach of the third edition. Finally, it looked at the fifth edition’s departure from Spitzer’s principles, with its focus on clinical rather than research utility and the conflict between the DSM-5 and RDoC projects. This chapter has also examined a number of the conceptual, ethical and practical problems of psychiatric diagnosis, including its reliability, validity and the appropriateness of a medical framework. Whatever your views about diagnosis, it seems likely that it will continue to have a significant influence on mental health for some time to come.
Further reading
This chapter provides a useful insight into the process of diagnosis, including the conceptual coherence and validity of diagnostic systems:Boyle, M. (1999) ‘Diagnosis’, in Newnes, C., Holmes, G. and Dunn, C. (eds.) This is madness: a critical look at psychiatry and the future of mental health services. Ross-on-Wye: PCCS Books, pp. 75–90.
This is a short, accessible introduction to some of the debates in the chapter. Chapters 3–6 are particularly useful:Johnstone, L. (2014) A straight talking introduction to psychiatric diagnosis. Ross-on-Wye: PCCS Books.
References
American Psychiatric Association (APA) (1952) Diagnostic and statistical manual of mental disorders (DSM-I). Washington: American Psychiatric Association Publishing.
American Psychiatric Association (APA) (1968) Diagnostic and statistical manual of mental disorders (DSM-II). 2nd edn. Washington: American Psychiatric Association Publishing.
American Psychiatric Association (APA) (1980) Diagnostic and statistical manual of mental disorders (DSM-III). 3rd edn. Washington: American Psychiatric Association Publishing
American Psychiatric Association (APA) (1994) Diagnostic and statistical manual of mental disorders (DSM-IV). 4th edn. Washington: American Psychiatric Association Publishing.
American Psychiatric Association (APA) (2013) Diagnostic and statistical manual of mental disorders (DSM-5). 5th edn. Washington: American Psychiatric Association Publishing.
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